Strained Mercy

Somewhere there may be a swimming coach who has never been in the water, but it is difficult to imagine that he is a very good one. Similarly, judges, legislators, and voters are making literally life-and-death decisions concerning legalized physician-assisted suicide (PAS) and euthanasia, this despite the fact that most of them have never even spoken with a suicidal person. Yet there is a vast corpus of knowledge concerning suicide and the depression that almost invariably precedes it. There are psychiatrists who specialize in management of the suicidal patient. Herbert Hendin, head of the American Suicide Foundation and Professor of Psychiatry at New York Medical College, is one of these specialists, and he wields his considerable expertise in this important book.

Hendin reports on euthanasia and PAS not merely in theory, but as it is actually practiced in the Netherlands, and he reports on extensive interviews he conducted with its chief defenders there. One hardly knows which is more chilling, the widespread flouting of the scant and effectively toothless legal regulation of euthanasia in Holland, or the sangfroid with which it is defended by the Dutch practitioners.

For example, Hendin presents the case of Netty Boomsma, a physically healthy fifty-year-old woman who lost her sons (one to suicide and one to cancer) and was shortly afterward divorced by her husband. She contacted the Dutch Voluntary Euthanasia Society, which referred her to Dr. Boudewijn Chabot, a psychiatrist who had previously indicated his interest in receiving such referrals. Chabot was to know her only a little more than a month before he assisted in her suicide. Netty was never personally evaluated by any other psychiatrist, although several consultants urged Chabot to proceed, basing their endorsement on nothing more than Chabots own written summary of Nettys case. After Nettys death, the local prosecutor, who personally agreed with Chabots action, made a tepid case against him. The Dutch court exonerated Chabot, and the medical authorities did nothing more than reprimand him for some procedural peccadilloes.

At least Netty, emotionally impaired as she was, consented to participate in this physician-assisted suicide”or should I call it a patient-assisted homicide? Yet, as Hendin reports, a Dutch government commission found that in about half of the 49,000 cases in which there was a medical decision at the end of life, the doctor chose a treatment whose primary or secondary purpose was to shorten the life of the patient”despite the fact that the patient had not been consulted on the matter. The Dutch delicately refer to this as termination of the patient without explicit request. Underlying this euphemism is the unchallenged assumption that the doctor knows best. Indeed, as Hendin demonstrates, the regulations placed on PAS and euthanasia in Holland are not designed to protect patients, but rather to exculpate the doctors who help or make them die.

Hendin explains that the abuses we see in Holland would pale in comparison to abuses in the United States were PAS or euthanasia legalized here. Exacerbating our prospects are the lack of the extensive family doctor system seen in Holland, the unequal access to health care, and the disadvantaged position of the disabled, racial minorities, and elderly.

When society gives the power of ending life to physicians, they will exercise it when they conclude that life is of no value. The physician becomes the final arbiter of lifes worth. Ironically, and quite contrary to their stated goal, by turning the physician into executioner the euthanasiasts effectively increase the medicalization of death and diminish patient autonomy.

Proper palliative care, by contrast, starts with the recognition of the value of each individual life, and seeks to maximize physical, emotional, and spiritual comfort. There can be no effective safeguards on legalized euthanasia and PAS when its practitioners share the contempt with which the suicidal dying and disabled view their lives. These euthanasiasts are themselves impaired, of course, unable to recognize the depression or terror that lies behind the patients request for expedited death. The second opinions the euthanasia doctors are obliged to elicit and the psychological consultations they are required to seek are worthless, because the euthanist only chooses consultants who share his fundamental disdain for what in less politically correct times were called useless eaters.

Hendin is at his best when he describes the multifaceted reality of the individuals who are at the center of this fatal drama. A sick person who seeks suicide is fundamentally no different from a physically healthy one who does. The vast majority of such people are clinically depressed, although all too often their doctors fail to recognize it. (Fifty percent of suicides consult a doctor within a month before their death.) Many of those who seek assisted suicide are in a state of terror. They are mortally fearful of debility, dependence, or even death. Some are so afraid of death that they would rather die than live in such fear. Assisting in such suicide does not promote patient autonomy and dignity. Rather it reduces the patient to a victim of his fear and despair, and it guarantees that he will not work through his fear and find value in his life.

Hendin also rightfully emphasizes the enabling roles of the physician, family, and society in this grim scenario. In Holland it is common for the doctor to be the first to suggest euthanasia to his patient. Given the disparity of power in a doctor-patient relationship, a doctors willingness to assist in a patients suicide is a strong signal that the doctor feels that it is the right thing to do. A sick patient often lacks the strength to resist such a culturally powerful figure.

In these matters, families cannot be neutral. Even if they say, Its up to you, Mom, when asked their opinion about a proposed suicide, their reply is correctly heard as indifference about the life in question. In a society where euthanasia is widely practiced, as in Holland now, the terminally ill and disabled have learned that the public at large finds no significant value in their lives. Far from dying in dignity, these tragic souls must live their final days as objects of strained mercy at best, or simple contempt at worst. At a time when his own morale is at its lowest, when the patient is most in need of encouragement and validation, he finds himself surrounded by figures of power and authority who feel that he really ought to just hurry up and die.

Unlike the Dutch euthanasiasts, Hendin has not been seduced by death. He has looked unblinkingly at the Dutch experience with physician-mediated death, and found not loving engagement, but institutionalized abandonment.

Eric Chevlen, M.D., is a diplomate of the American Boards of Internal Medicine, Medical Oncology, Hematology, and Pain Medicine. He is Director of Palliative Care at St. Elizabeth Health Center, Youngstown, Ohio.